Monday, September 12, 2016

NHS: Changes by Stealth!

As summer will soon be over, take one last look at the NHS. Will it last longer than the flowers:

There are some very smart people working for Simon Stevens where the changes to the NHS is now being undertaken without going through any legislation. The idea is to persuade people that hospital is a bad place to be and you are better off not going there. Stay home and look at your flower!

GPs are being asked to do more and more and as they are generally paid more than Hospital Consultants they are now starting to complain and payment for service has meant that unpaid work will soon not be provided. The erosion of good working relationship between GPs and Consultants is now history. The bright young things that wanted to do advance medicine are now going west or is it south east including the daughter of our ex-doctor MP.

Yet we have very smart looking social media saavy people promoting the new NHS as if they are selling Time Share. Everybody is now a leader. Where you might ask are the workers. The Internal Market will be kept in part and in other parts will be phased out. So my question is: why not let hospitals run everything? No more payment for A&E, just one simple annual fee! Enjoy the flowers before your stent!

If you think there is anything new about an integrated NHS, think again. It has been done elsewhere: USA. It is being proposed here in poor areas where ---EM!--- no one wants to be a GP there. So it is about solving a problem and glorifying it as integration.

And Stevens' PACS (part of Vanguard) are explicitly modelled on San Francisco's Kaiser Permanante’s Accountable Care Organisation model (a latter development of the American HMO model)- despite US concerns about restrictions on which patients can be treated where, long wait times, and still high costs.

I asked a friend in California recently what Kaiser were like. She smiled, “Oh they're great! ‘Til you get sick”. Their focus on prevention and health resilience belies a reluctance to provide full health care that might cost shareholders their profit. Only a top-up payment plan will see you in the real hospital.

“Be the Change You Want to Be...”

We are learning as quickly as we can. But the actions and spin of NHS England and the corporate health, insurance, technology and pharma companies are bewildering and confusing to those of us trying to keep up. Just as we’d begun to get our heads around 2012’s Clinical Commissioning Groups (CCGs) and Commissioning Support Units (CSUs), new NHS boss Simon Stevens’s Five Year Plan ushered in a new layer of jargon and organisational spaghetti – Primary & Acute Care Systems (PACS) and Multidisciplinary or Multispecialty Health Teams (MHTs).

If you read it thinking it made any sort of reasonable sense - then we need to worry.

One of the key weapons being used against the NHS, public and campaigners is the growing misuse of socially minded vocabulary and community development buzzwords.

You’ll find these buzzwords all over the NHS, mixed with a dash of new age personal therapy speak borrowed from the West Coast of America (as we’ll see shortly, there are other imports from the West Coast, too).

……. This dishonest vocabulary aims to fool the public into supporting a host of dubious changes. It relies on a counterpoint image of a desperately archaic NHS, crumbling in an inevitable apocalypse of overweight aging diabetic bed blockers who really should know better and die in their own beds – “Care Closer to Home”.

It glosses over the fact that public funding is being withheld (and wasted on market bureaucracy).

The two main new models of care – the GP-led ‘multi-specialty community providers’ (MCPs) and the hospital-led ‘primary and acute care systems’ (PACS) – were included as part of NHS England’s Five-Year Forward View.

It had said that MCPs will be the more common new model, withPACS only established in areas of poor GP recruitment.But nine of the 29 bids approved were from hospital-led organisations.

The new models will employa mix of primary and secondary care staffto deal with commonly encountered conditions such as diabetes, dementia and mental illness. Some will see some employing‘social prescribing teams’who will be able to refer patients to voluntary organisations and local authority services.

(Read the small print: Staff means Staff )

On last count: over 20 million patients would have attended A&E: A rise from 12 million around 10 years ago!

It is not difficult for anyone in the NHS to see how the internal market has continued to fragment and disintegrate our health service.

Attempts to badmouth our Hospitals and their A&E department did not seem to put people off and attendances continue to climb.

NHS:

A trusted Brand? So the Genius is going to pump £500m in, well a small sum compare to £42 billion for RBS.

It is important for SoS/Genius to recognise that the extra money should go directly to hospitals to salary employed staff and not for the likes of Harmoni or Serco to offer a service that punters (sorry, patients) no longer believe in. Did the Genius realise that for OOH and the like there is no control as to who was making the calls. If Serco could fake data.....Well!

While you are at it, cancel all UCCs as punters prefer A&E (so do not change the name to ED or worse, ER). Abandon the market system too.

In a Market system, A & Es are run by Hospitals and OOH by CCG/GPs; business rivals so to speak. Hospitals wants to maximize income and CCGs did not want anyone to attend A & E if at all possible. NHS A & E: Unpredictable, Unruly & Ungainly

The Genius knows that the GPs are too powerful and will not take back OOH unless there is a lot of money. so the funding to A&E should not be via CCGs although the hospitals have a system of charging CCGs and that was the bit CCGs do not like. Do not wait, Genius as the objections from the GPs will be coming. Employing more GPs does not cure the 24/7 coverage problem at all.

Also, why not cancel CCGs and let hospitals run everything. They are committed to 24/7 service, aren't they? -

‘There is no evidence that GPs as a group are empowered with supernatural abilities to manage large budgets and organisations’

The right configuration?

So what would be the main characteristics of an alternative system based on previous experience? The key features would be:

· Integration of service provision and planning around a defined population and individual patients.

· The best degree of fit possible with social care and other local government services.

· Integration of support services for the defined population, crucially finance and information, to reduce unnecessary overheads.

· Consistency of policy around the key indicators of health of populations, patient outcomes and their experience so comparisons can be made across organisations and time.

There is no right answer to the configuration of health organisations across England and the solution will always be a compromise. However, experience would suggest that London is always a special case and should not influence the best arrangements for the rest of England.

Unnecessary division

For the last 20 odd years, dividing the health service into commissioning (or purchasing) and provision has been the only show in town. First, NHS trusts were divided from health authorities and GP fundholders added to spice the brew. Then primary care trusts were created with practice based commissioning bolted on.

Interestingly, in both cases, GP purchasing/commissioning was run in competition to health authorities/PCTs; rather than to provide synergy. When this ran into difficulties, particularly in restraining the costs of acute trusts, the “world class commissioning” programme was created and PCTs were encouraged to buy in all the best brains in the private sector to smarten up their act. PCTs were even forced to divest themselves of direct management responsibility for community services in case this sullied the purity of their commissioning role.

Now all faith is being placed in clinical commissioning groups and GPs being the magic ingredient that will make commissioning the powerhouse of efficiency and effectiveness in the health service.

The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham or Oxford, when it is not Oldham or Oxford that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me.

…….Instead let them help the NHS do what it does best — treat patients, and do so efficiently and economically without the crucifying expense and ridiculous parody of competition.

This is not on when you have an internal market system. Through A & E, Hospitals can admit patients without a referral and believe you me, whatever anyone might say the CEOs of FT Hospitals are quite pleased with that.

For CCGs, it is becoming uncontrollable. All Hospital Avoidance tactics will not work. Funding will flow uncontrolled to FT Hospitals.

I have written about this earlier and I will simply reprint them. It is more true now than ever.

Wait: where are the real specialist doctors? And NHS referring to Voluntary Organisations?

Thank you for your visit.

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A budding child psychiatrist

About Me

Before my retirement, I practised child psychiatry for 30 years, 25 of which as a consultant and director. After these years of clinical practice, I felt compelled to tell my stories as I have my doubts as to the validity of some of the assertions of the medical world.
I am the author of the book The Cockroach Catcher, which is based on my work as an NHS child psychiatrist. Contact me on: cockroachcatcher at gmail dot com

Eric Kandel, M.D., who was awarded the Nobel Prize in 2000 for discovering molecular mechanisms of memory storage, told the crowd at last ...

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